Error in Syringe Markings Leads to Under-Dosing
In an unfortunate incident at Bukit Merah polyclinic, 117 individuals, including both patients and staff, received only one-tenth of the recommended Covid-19 vaccine dosage between Wednesday and Friday (Oct 20 – 22). The oversight stemmed from a misreading of the markings on new syringes introduced at the facility, according to a statement from SingHealth Polyclinics released on Sunday.
The issue directly impacted six staff members and 111 patients who were vaccinated with the Pfizer BioNTech/Comirnaty vaccine. The error came to light on Friday when another colleague was assisting with vaccinations. Subsequent investigations by SingHealth confirmed this to be an isolated case, not affecting other services or vaccinations at their clinics.
Adrian Ee, the CEO of SingHealth Polyclinics, issued an apology for the distress caused, promising swift action to address the concerns and to schedule replacement vaccinations. “We have taken immediate steps to rectify the error, ensuring that our staff are now well-versed in the use of these new syringes,” Ee stated, emphasizing the review of their processes to prevent future occurrences.
Following the incident, SingHealth Polyclinics promptly contacted those affected to assess the situation and assure them that, based on Ministry of Health guidelines, the lower dose was unlikely to cause harm. They will be assessed by a doctor before receiving their correct dose as an additional safety measure.
This incident echoes previous vaccination mishaps in Singapore, including one in January where a staff member at the Singapore National Eye Centre was inadvertently given five times the usual vaccine dose due to a dilution error, and in June, when a minor was mistakenly vaccinated at Kolam Ayer Community Club due to an age verification oversight.
